Giving life from the deceased, but not with amen from religion
Religious communities reserved to transplants from the deceased, pointing to possible abuse of donated organs due to the consent required from the family, and variously interpreted
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Macedonian citizens are generous not only during floods. On the contrary, once, at the time of the former Yugoslavia, they decided to bestow life quite emotionally. Thirty years ago, in Macedonia there was a real revolution in terms of organ donation from deceased persons, but today the whole process is seen as pretty skeptical. The comments go towards eventual possibility of abuse of donated organs, something that religious communities placed in a question mark.
In one year – one transplant from a deceased person
Within one year since the new legal amendments to the Law on taking and transplanting parts of the human body for treatment became valid, so far only one transplant from cadaver i.e. deceased person has been carried out (a person with brain death). The first transplant from a deceased person was carried out in February this year . Two patients received kidneys and the transplant which was carried out for the first time after a long break, was considered successful. But the pace of cadaveric transplants in the country still lacks a dynamic flow, like the eighties when in two years even 18 transplants were carried out.
“Five kidneys were sent to Belgrade, two in Rijeka, one in Ljubljana…It was a small revolution of our specialists. Macedonian citizens sent their kidneys in the former Yugoslav republics. Then there was a sound legal framework that protected us as professionals. People gave their close family for transplantation”, some Macedonian doctors recall with emotions the peak of cadaveric transplant in the country.
Unlike then, in the country at present there are still doubts and ignorance about the importance of cadaveric transplant. That is how doctors explain the doubts related to cadaveric transplants, for which they have tried several times to secure the consent of the family of deceased persons, but failed. Sometimes, according to them, the family simply refused organs to be taken from their close ones, in other cases, however, wanted to know who would get the organ.
Cadaveric transplants are carried out from brain-dead persons, when it is determined that the patient cannot recover in life. The procedure goes in a way that consent from the family of the brain-dead patient is initially required, and a special team of doctors talks to the families of such patients. However, it is uncertain whether the family would agree organs to be taken from their close one without compensation, of purely humanitarian reasons. Especially in the moments when they are told that their close one is dead, because under the legislation it must be done within six hours after brain death is ascertained.
Everyone is a potential organ donor
In Macedonia so far transplants have been carried out from living donors, mostly from donors who are blood relatives of the patient. For the others, however, special consent is required from competent to exclude any abuse or material compensation.
With the new legal amendments that again actualize cadaveric transplants, virtually anyone can be a potential organ donor. And if a citizen wants to oppose his organs to be taken in case of certain death, while still alive he will need to certify a notary statement that he opposes it, reporting the statement to the relevant institutions. Second choice for him is after his death, the family to decide.
This results from Article 28 of the Law, which states that:
“Parts of the body of a deceased person for transplantation can be taken if the deceased person during life expressly with notarized statement did not oppose to it”.
The same article states that no body parts of a deceased person shall be taken if the family members within six hours of the brain death submit a written statement that they do not agree with it. This is particularly questionable for representatives of NGO “Nefron”, which represents the rights of patients with kidney diseases:
“So anyone who does not oppose to give an organ after death, must go to a notary to make a statement and pay for it, then take it to another institution to accept it. Regarding the European experience, it is a fact that apparent advantage is given in taking organs from a deceased person, negating the consent of the family. We cannot fail to respect the family in the act when they feel the greatest pain, the family suffers all psychological, social, and if you want the material consequences of the deceased. It cannot be denied. Therefore, despite this law, I am convinced that my colleagues working in the clinics obey the unwritten rule that, however, they talk to the closest or relatives about possible organ donation, though not signed by the man while he was alive. It is the inverse limit consent”, explains Dr. Prim Ljubinko Trpenoski, President of the Association “Nefron”.
The dilemma which puzzles the interviewed doctors is whether there should be or should not be consent from the family. Some of them say that although legally consent from the family is not prescribed, they still do not dare to take an organ unless they previously obtain consent.
“As a rule, all those who do not submit statements that they do not oppose taking organs, are automatically organ donors. But as it is a pretty emotional and essentially burdened ethical problem, we, as medical professionals, have not dared to take an organ of a deceased person without talking to his close family. It is not legislation, it is more ethical framework. Only when we have obtained consent from the family, we proceed in taking the organs”, says Dr. Ninoslav Ivanovski from the Nephrology Clinic.
Unlike him, for Dr. Saso Dohcev, head of the Centre for Transplantation, family consent is crucial in taking organs from the deceased, and that is in the Law according to him.
“Organs can be taken only with the permission of the deceased, and the family has the last word”, says Dr Dohcev. He explains that a list for cadaveric transplant is prepared, on which there are about 80 (classified) patients, but predicts that certainly there are more than 200 who have no living donor. Macedonia, highlights Dohcev, is currently the leader in the immediate environment according to the living donor transplants, and according to him, the country ranks just behind Croatia, which is first in the region. However, for cadaveric transplants, Dohcev, as well as his colleagues, believe that more campaigns are necessary to promote the values of this type of transplant.
Religious communities reserved to transplants from the deceased
It is the consent of the family, at the moment differently interpreted in doctoral profession, the one causing doubts among religious communities.
Macedonian Orthodox Church strongly opposes the possibility everybody to be a potential organ donor.
“We do not approve it. We, as religious communities, were not involved in making the law. We believe that this is not permissible. Everyone should leave consent whether he wants his organs to be donated or used for medicinal purposes. Law must be extended and predict it. Each of us should leave written consent for organ donation. For example, it often happens, mandatory autopsy to be prescribed, which for us is leaving the possibility that something could happen. This must be strictly controlled because there can be abuses. Firstly, we do not know whether the organs will go to the right place. Secondly, we do not know whether someone is making a particular trade with that, even the state, because it can happen here a center of power to use it for its own benefit, and no one has control over it. Therefore, we believe that the consent is a good method that should be maintained”, says Boban Mitkovski, assistant at the Theological Faculty and chief of staff to the head of the Macedonian Orthodox Church, d. d. Stefan.
The church, according to him, preaches that a clear limit needs to be put on when death occurs and whether it is brain death, and that the donor must be specified. Although generally MOC approves organ donation, under strictly defined criteria.
Islam as a religion does not approve of taking organs from someone if the person is deceased, that is all his organs are dead.
“Taking organs from a cadaver can be done only when death is definitely established, not when the person is brain-dead. You need to ensure consent that an organ can be taken from a dead body. This can be submitted by the person himself, with his will before he dies, leaving a message that organs from his body can be taken, or it can be done with consent by his closest relatives”, Saban Sulejmani, Professor of Islamic law explains the principles of the Islamic faith. But he adds it would be best if the person gave permission for organ donation while still alive.
According to Islam, a person can have an organ transplanted a cadaver only in a situation when no living person can be found to donate an organ and if it is found that cadaveric transplant is the last remaining option.
About fifty citizens have offered doctors a kidney for sale
While waiting for cadaveric transplant to revive, citizens continue to offer their organs for sale. Over 50 citizens have so far offered a kidney to doctors in order to profit from it. The last case they unveiled for “INBOX 7” is from last year. The reasons cited are economic, and it is about a different profile of people, including intellectuals. The prices that they offered for their organs move from 20,000 to 30,000 Euros.
“There are attempts people to sell kidneys. At least fifty have come to me to offer a kidney. For money of course. They all have a bizarre life story with poverty, but it is something incompatible with us. According to what they say, they even want me to connect them with the places for sale, which is absurd”, emphasizes Dr. Ninoslav Ivanovski. In the world, tells Ivanovski, there are most illegally sold organs in Turkey, Egypt, Pakistan, India…Prices range from 2,000 to 2,500 US dollars.
“The whole procedure costs 30,000-40,000 Euros which is shared between dealers and doctors. It is an illegal procedure connected with a big crime, something that is beyond any human aspect”, says Ivanovski. But he adds that here an attempt has been prevented for illegal organ trade.
“Israeli teams came to offer us to be a hospital where they would operate and where we should not care who is transplanted and where they would bring donors from. But we turned it down as we saw that it was about a sale of organs. There were such attempts in the mid-90s, but then it stopped”, says Ivanovski.
In Macedonia, from time to time, Internet advertisements can be seen for kidney sales. Legally, this is not treated as a crime, MOI says. So far no criminal charges have been brought in connection with these advertisements.
About ten people have received an organ abroad, but diseases, too, including HIV
There is no legal possibility to prevent someone going overseas and there to seek or buy an organ. Some of the patients waiting for an organ, desperate to solve their health problems more quickly, have been abroad and returned with a bunch of problems.
“In Macedonia, according to my estimation, there are around 15 people who have had transplants in other countries, like Pakistan, in recent times, Egypt and an older case from India. Completely illegal. These patients came to us after transplantation and here we continued to monitor them. But according to estimates, the total number of our patients who have been in other countries is between 30 and 40 for the entire period after the 90s, most of whom died due to complications related to the transplant. These are usually infectious complications of bacteria and parasites that we do not have here. Patients say that the conditions there had been pretty unsanitary, not hospital. In general, it is playing with life. Normally, patients do not think of anything else, but it is playing with life”, says Dr. Ivanovski.
According to his colleague from the Nephrology Clinic, Dr. Igor Ivanov, patients from abroad have returned with hepatitis B and C, and there is a patient with HIV received with the organ itself.
Participation exemption for each donor
Cadaveric transplant was discussed at the first meeting of the new Government. Prime Minister Nikola Gruevski, in a Macedonian television interview, said that each organ and tissue donor will be exempt from participation in health care, while doctors and support staff who will perform cadaveric transplants will receive special holiday compensation.
How is cadaveric transplant regulated in Croatia?
In Croatia, the leading country in the region in cadaveric transplants, consent for giving organs is obligatory, unless the citizen, while alive, did not oppose with a written statement filed to his doctor. In Croatia, every citizen can get a donor card and while still alive to agree his/her organs to be transplanted after death.